Job Description

Intermediate Care Lambeth provides integrated health and social care at home to adults aged 18 years & older who live in the borough of Lambeth. The people that we support have a range of diagnoses and clinical presentations.

Our service aims to:

Facilitate the safe discharge of people from healthcare in hospital to healthcare at home.

Provide intensive, short term multi-disciplinary rehabilitation & care support to promote functional independence.

Our Professional Offer to You:

Further develop your clinical skills Develop your skills in holistic assessment, problem solving, intervention planning and joint working with other health and social care colleagues. Develop management and operational skills. Access appropriate GSTT leadership development training courses to support career development. Support you to be involved in Physio meetings and In-service training. Provide supervision and clinical support.

At GSTT we are committed to providing:

Professional expert advice, including access to our Professional Leads in our Community and Hospital settings. An annual appraisal and PDR. Structured in-service development programs and supervisions. Support to undertake research, audit and service evaluation. Training links to London Southbank and King's College Universities. Support to develop your skills in preparation and presentations

Have responsibility for specialist rehabilitation and therapy assessment, specialist intervention, care planning and review of individual clients.

Delegate tasks to RSWs

Case manage people through intensive short term rehabilitation programmes. Goal setting with clients to maximise independence, facilitate early hospital discharge, reduce reliance on care and reduce admissions to long term domiciliary care.



Work, as a lone practitioner and at times with colleagues, across a variety of locations within the community to meet the needs of a multi-cultural population in an inner city area.



Work as an autonomous practitioner complying with the standards set by the regulatory body (HCPC), professional body (CSP), government, Trust and department, thereby being professionally and legally responsible and accountable for all aspects of own work and to meet the requirements for professional registration.

Work as part of a flexible multidisciplinary team, across traditional professional boundaries to meet the needs of clients using a holistic and client centred approach

To be responsible for practice, education, assessment, mentorship and preceptorship of students and new/junior members of staff. To work towards organisational priorities and achieving service aims.

Support the department's commitment to meeting patient needs and delivering excellence it is essential the post holder be able to work their hours and contribute to both rotas over a 7 day week, including weekday and weekend.



About the Trust



Guy's and St Thomas' is among the UK's busiest and most successful NHS foundation trusts. Our adult community services teams deliver care at the heart of the local communities we serve, working in partnership with GPs, local authorities and other healthcare and voluntary sector organisations.



Patients are at the heart of everything we do and we pride ourselves on ensuring the best possible patient experience as well as safe, high quality care. Following a comprehensive Care Quality Commission (CQC) inspection in 2019 we maintained our overall rating of 'good'. Our adult community services achieved a rating of 'outstanding'.



Integrated Local Services (ILS) at Guy's and St Thomas' NHS Foundation Trust provides a range of community and inpatient health services for adults within the communities of Lambeth and Southwark. Our hospital-based inpatient and outpatient services provide care for adults from across the region.



Our services range from health promotion through to delivery of high-quality care for complex patients in the community centres.



Our values

Our values help us to define and develop our culture, what we do and how we do it.

It is important that we all understand and reflect these values in our work. We are:



Caring - we put patients first

Ambitious - we innovate and strive for excellence

Inclusive - we respect each other and work collaboratively



Professional / Clinical responsibilities

To be professionally and legally responsible for own practice and accountable for all aspects of treatment delivered to the client to ensure a high standard of clinical care. To work as an autonomous lone practitioner, case managing clients in the community and co-ordinating their care. To carry out timely assessment, treatment, goal setting and rehabilitation of community clients to prevent admission or re-admission to hospital or long term domiciliary care and to facilitate early discharge home from hospital. To be competent in using a wide variety of specialised assessment and treatment approaches with adults with a range of conditions, including those with severe physical and cognitive impairment or multiple diagnoses in order to formulate treatment plans, maximise rehabilitation potential and set goals. Using advanced clinical reasoning skills, analyse and interpret complex assessment findings, from both standardised and non-standardised assessments in order to formulate an accurate diagnosis and prognosis. To be able to analyse and interpret complex clinical and social information from a range of sources. To ascertain rehabilitation potential of clients following assessment and devise both uni-disciplinary and multi-disciplinary rehabilitation goals which address clinical rehabilitation needs, client choice, service criteria, urgency of need and clinical risk. To be able to identify significant health changes that would warrant medical intervention and liaise with the relevant practitioner in a timely manner. To educate clients, carers and family members on the client's medical condition, prognosis and physical management encouraging their involvement and actively promoting healthy lifestyles. To implement a range of interventions including, but not limited to, physical and cognitive rehabilitation in functional tasks, work and leisure. To undertake patient moving and handling assessments, make recommendations and provide training to informal carers when required. To provide recommendations for posture and seating, minor home adaptations, and specialist housing. Assess clients' needs for any rehabilitative equipment and aids to improve safety and functioning within the home as part of a Trusted Assessor role. To train RSW's, therapy assistants, students, informal carers, family members in the use of appropriate equipment. Demonstrate the safe use of equipment to external providers of care where appropriate. Assess and manage clinical, physical and/or environmental risk. To adhere to incident reporting procedures and to support RSWs to do likewise. To act as lead health professional for clients when required. This may include initiating and co-ordinating multi-disciplinary/multi-agency meetings, liaising with clients/families and onward referrals to other professionals/agencies. To identify significant health changes that would warrant medical intervention and liaise with the relevant practitioner. To liaise with the multidisciplinary team and identify when referral on to other professions within the team or outside agencies is indicated. This may include making recommendations on package of care needs when appropriate. To maintain accurate and up to date individual client records and ensure safekeeping and confidentiality of these records (including use of the Trust electronic patient records system) in line with Trust, legal and professional requirements. To evaluate client intervention and progress in a timely manner using appropriate outcome measures and evaluation tools. To adapt care plans accordingly and delegate tasks appropriately to RSWs. To discharge clients in a timely manner having reviewed the client's needs and goals, making appropriate onward referrals where necessary. To participate in the duty therapy rota for the single point of access, responsible for triage and prioritisation of new referrals. To respect an individual's ethnicity and cultural and religious beliefs.

Communication

To be highly skilled in effective communication, using both verbal and non-verbal means, with clients, carers and families who may have a range of physical disabilities or other barriers to understanding. To work in a client centred manner with mutually agreed goals, appointments, and rehabilitation programmes. Develop effective working relationships with the multidisciplinary team and external agencies. To be able to respond calmly and patiently to clients, carers and family members who may be distressed and sometimes aggressive. To offer support, reassurance and advice as required in order to diffuse the situation. To offer advice and communicate written and verbal information to clients/ carers and agencies including other health professionals regarding a client's management. To attend regular multidisciplinary meetings, presenting relevant information about client caseloads in a clear and concise manner.

Management & Leadership

Undertake supervision and appraisal of RSWs and Senior RSWs, junior staff or therapy assistants when required in line with service needs. To delegate tasks to therapy assistants, RSWs and junior staff, providing clear instruction and modifying tasks and care plans as appropriate based on feedback. To participate in the recruitment and selection of high calibre staff into the community therapy/rehabilitation teams. To ensure that all complaints and incidents are reported and managed in line with trust complaints procedure policies. To monitor the quality of the services offered and contribute to the development and review of quality measures and performance indicators. To manage and maintain stock levels and safe keeping of equipment, supplies and aids. To implement relevant national and local guidance, policies and procedures. To act as a lead in key areas in line with Trust priorities and actively engage in service development. To ensure all written and verbal feedback is clear, concise and accurate. To identify areas requiring service development and to highlight these to management.

Education, Training & Mentorship

Provide clinical training and education to junior staff and other staff including RSWs and Senior RSWs in line with competency frameworks. To induct new staff and develop induction procedures if required. To induct, supervise, appraise and teach students on placements within the team. To undertake all mandatory and statutory training in line with Trust policy. To educate referrers and clients about the services the team offers. To maintain skills within the team, identifying gaps, then developing and implementing a plan to address these. To continually update clinical practice in accordance with current research, evidence based guidelines, audit results and government legislation. To actively participate in Rehab and therapies in-service training program, undertaking a project / presentation for staff using advanced presentation skills.

Audit, Benchmarking & Research

To participate or lead on clinical governance activities such as audit, research and data collection as required. To monitor the quality of services offered by the team and when areas of development are identified, to implement an action plan to address these under the direction of the Reablement Team Manager and GSTT Clinical Manager.

Personal & Professional Development

To work within local and national clinical and operational standards and guidelines. To be professionally and legally accountable for all aspects of own work including management of clients in your care. To maintain and update knowledge and skills in line with personal development plans and appraisal. To use evidence based practice to develop and maintain a high quality clinically effective and cost-effective service. To participate self-appraisal and performance review. To identify and be responsible for own training needs as well as identifying team training needs and supporting development of others. To reflect on practice at all times and to effectively participate in clinical supervision. To positively engage in change management. * To maintain Health and Care Professions Council (HCPC) registration and to work within HCPC Code of Conduct.